Armoring First Responders with Stoicism: A Review of the Before Operational Stress (BOS) Program
I was all of 18 years old when I first stepped into the back of an ambulance as an Emergency Medical Technician (EMT) student. While the curriculum of my EMT program included instruction in Critical Incident Stress Debriefing (CISD), I don’t recall ever attending one. My training as an EMT little prepared me for the psychological shock of emergency medicine. I would often ruminate on unsuccessful rescue calls blaming myself for some perceived failure. Occasionally, I would wake from a nightmare as I relived the pure panic of watching the death of an infant. While I weathered the storm of my experiences, a preventive approach to psychological resilience may have saved me from needless suffering.
I watched the failures of poor resiliency programs during and after a deployment to Iraq. Divorce, homelessness, substance abuse, and suicide became common place among the veterans of my generation. The resiliency program supplied to soldiers as an immediate stop-gap for the growing suicide rate within the US Army was originally designed for middle school students (ages 9–14). While this program was better than nothing, you can imagine the problems caused by introducing an overly-simplified resiliency program into a community that was in need of a program custom designed for their culture and extreme-stress environments.
Only after twelve years since I first entered public service did I discover and understand the connections between ancient Stoic philosophy and modern psychology. I learned how Albert Ellis built on top of Stoic principles to create Rational Emotive Behavioral Therapy (REBT). This further evolved into Cognitive Behavioral Therapy (CBT) that is often used to treat critical stress injuries. To think, I spent over half a career lacking the knowledge that could have greatly inoculated me against the harmful impacts of stressful events. There had to be a better way. Finding a Stoic-base purposely built resiliency program that could be provided upon entry into public safety/military service would be the proactive psychological intervention needed to safeguard these critical communities.
Before Operational Stress (BOS) Program
A little over a year ago, while hosting a Stoic conference for the Office of the Chief Surgeon of the Army National Guard, I was introduced to Dr. Megan McElheran of Wayfound Mental Health Group. She had developed a Stoic-based resiliency program specifically for the public safety community. Much to my joy, not only was she piloting this program, but it was producing statistically significant deductions in Post-Traumatic Stress Disorder (PTSD) symptoms among participants. Wounded Warrior Canada has graciously funded a three-year pilot of this program to include the cost of independent evaluation through the Canadian Institute for Public Safety Research and Treatment (CIPSRT). The only fault I could find with the program was it was being tested in Canada and I hoped for a way to bring it south across the border.
BOS Format
The BOS program is carried out in two phases. The first being consecutive course work for eight-weeks (active phase). A maintenance phase would follow with monthly follow-ups for ten months. The first phase of the program was built around the following topics:
Operational Service Culture. This module introduces the course. This includes discussions of key terms and the larger service culture in which an individual may operate.
Physiology of Operational Stress. This module discusses how the brain processes traumatic experiences. This includes an explanation of the various brain structures involved in responded to high-stress environments and why certain behaviors such as “freezing” may occur.
Markers of Operational Stress. This module explores the psychological impact of unresolved trauma. This includes discussions of hyper- and hypo-arousal and how an individual might attempt to regulate these conditions within a window of tolerance.
Cognitive Impacts. This module discusses the interaction between thoughts, emotions, and behaviors. This includes techniques to interrupt unproductive patterns in thought.
Emotions. This module discusses emotional awareness and the influence of cultural expectations with the goal to avoid the suppression of emotion.
Behaviors. This module addresses avoidance behaviors and how they may hinder with the recovery process.
Communications. This module discusses the negative impact on communication caused by stress and offers communication skills to improve interpersonal understanding.
There was no set topics for the maintenance phase of the program. This allowed participants to freely interact with each other and the topics presented in the course. These facilitator-supported sessions that explored how the participants were integrating the lesions of the BOS programs into their personal lives. The peer-learning aspect of the maintenance phase highlights the advantages of conducting in person courses as participants not only learn from the BOS faculty but more importantly through the thoughts and experiences of their direct peers. In this way, the learning environment helps shape the desired service culture of public safety personnel freely sharing their thoughts and emotions about their daily service experiences.
BOS Online
In a brilliant move that could drastically increase the accessibility of this program, the BOS curriculum was built into an online learning program, now available at wayfound.ca. I was recently given access and I want to relay my thoughts about the program.
Target Audience. I would clearly say that this program is designed for individuals initially to the field of public safety. Experience individuals, especially ones that have done self-study into critical stress injuries / PTSD, might find they have already acquired much of the information presented in this course. However, I will admit that this course would be beneficial for all members of the community especially as we seek to build more supportive cultures.
Supports Cultural Change. I really have to compliment Dr. Spasojevic in her presentation of the “connecting the dots and the importance of processing” lesson. I have never seen it so clearly stated why talking about our experiences is so critical to recovery. If we want to build a culture accepting to mental health, every member of the community must understand and support this communication requirement. Unlike other resiliency programs I have been introduced to, the BOS program clearly offers advantages in trying to space the larger organizational cultures that public service providers operate within.
Purpose Built. This program was clearly purpose built for the first responder community. Having been exposed for a program designed for children, I can say this one clearly will treat you like an adult. The lessons are appropriate for an adult learner with all the correct terms and psychological concepts. The language, while clearly stated, is not over-simplified. The advantage of approach is it allows participants the information needed to engage in further self-study outside the program if they desire to do so. The examples of stressful environments within the course come directly from those that might be experienced by the public service audience. Thus, the examples examined are directly relevant to the needs of this community.
Stoicism. While this program is Stoic-based, don’t expect to be overwhelmed by Stoic quotes. Dr. McElheran certainly references great Stoics, to include Marcus Aurelius and Seneca, but it is done in practical language to relay some of the beneficial Stoic practices related to resiliency. Theses references are not “chapter and verse” in nature. While a detailed review of Ancient Stoic material may be missed by diehard Stoic fans, I believe the simplified and modern language approach to these concepts to be the most appropriate for the intent of this course. However, I do hope that this course will inspire those who don’t have an abundant knowledge of the Ancient Stoic philosophy to do some self-exploration into the great Stoic works.
Quality of Instruction. I found the course to be in a superior format with quality video and audio. The online course is truly self-paced. The video modules are between one and 13 minutes in length, making it easy to jump on the program and listen to individual models whenever you have a moment of free time. The quality of instruction from Dr. McElheran, Dr. Spasojevic, and Dr. Carlquist is superb. Brad Holms (paramedic) and Ray Burns (firefighter) provide useful insights in applying the techniques taught in the BOS program. I appreciated the minimal use of computer graphics. They were only applied when appropriate to advance learning. This prevented graphic distractions common with other programs.
Value. Priced at $199, I find this course to deliver value that far exceeds the cost. For the length and depth of this course, I would have guessed it would have been priced higher. I have seen programs of similar length charge three times this amount (even with an inferior product). At this cost, I will likely purchase the programs for my sons if they ever decide to enter into public safety or military service. I certainly would have saved myself significant hardships and suffering if I could have invested into this type of program before I began my career in emergency and military medicine.
Peer-Learning. My only complaint I have about the online BOS program would be the potential loss of peer-learning. This is not the fault of the program’s design but a general problem with online learning. One of the things that can make in person training so effective is the ability to interact with your peers. They often provide insights and experiences that are not presented in the formal training. It is obvious that taking this class online and independently creates a loss of this peer-learning environment. I have to compliment the BOS team in having the wisdom to include short video interviews with veteran public safety personnel to provide at least some peer-learning opportunities. For those interested in taking the online course, I would recommend trying to take this program along with others to allow for conversation about the various reflection exercises.
Recommendations. Coming to this program hoping to find a Stoic-based resiliency program for the military, I hope to one day see this program a little more optimized for the military community. The online program could be easily adapted to include “tracks” for various different public safety specialties. Just as now they have video discussions with veteran firefighters, the program could be expanded to include these discussions with military veterans. Furthermore, Dr. McElheran does briefly discuss the use of common military voluntary discomfort exercises with this program. However, I would like to see further instructions on how to establish routines of common voluntary discomfort exercises (like rucking) to further build military resilience and fitness.
Program Expansion
With the great success of the program, I am happy to see it continue to expand. Recently the BOS program received a grant to allow for 100,000 participants to access the online BOS program, 3,000 participants to attend a virtually taught BOS program, and another 300 to attend in-person training. With continued review by the CIPSRT, I predict we will continue to see this program produce the positive clinical results demonstrating the effectiveness of Stoic-based resilience. As the program continues to grow and expand, I hope to see it cross the board in the near future to be tested among US Military personnel.
Conclusion
Public service and military personnel are often exposed to operational stress capable of causing significant harm. While this harm can be treated, offering proactive instruction in resiliency techniques could minimize the need for this treatment and reduce the suffering of this community. Many have long desired a Stoic-based resiliency program be developed for this community. Dr. McElheran’s BOS program not only fulfills these desires but has also clinically demonstrated the reduction of PTSD symptoms by utilizing a Stoic-based approach. The development of an online version of the BOS program offers to extend the reach and positive influence of this program. I have little doubt that the BOS program will continue to grow and positively impact the cultures of the organizations that adapt this program.
The views presented are those of the author and do not necessarily represent the views of Department of Defense or its components.
